A lack of checks on patients tranquillised while under the care of the region’s mental health trust has been branded as “appalling”.

Fewer than one fifth of patients at Norfolk and Suffolk NHS Foundation Trust (NSFT) may not have been checked often enough, interim director of nursing, quality and patient safety Dawn Collins revealed today (Thursday) at the trust’s board of directors meeting.

Documents setting out the organisation’s priorities for 2018/19 said proof that patients who had been tranquillised had been checked often enough were filled out just 18pc of the time.

Medical director Dr Bohdan Solomka was tasked with ensuring the rate was brought up to 95pc by the end of March next year.

And chief executive Julie Cave questioned whether the jump from 18pc to 95pc was achievable.

But Dr Solomka said they were not talking about hundreds of patients and was confident he could achieve the goal.

When rapid tranquilisation is used, the National Institute for Health and Care Excellence (NICE) say patients should be observed once every hour for four hours, and a form must be filled out to prove this was done.

Service user governor and GP Dr Richard Gorrod said the current rate was “appalling” and added: “I think we should be aspiring to 100pc. We’ve talked about all the things which need resources, but this is something which is potentially life-threatening, and especially if it is a small number of people.”

NSFT placed him in a bed in Hamilton House care home in Catfield as they did not have enough beds for him. But when his condition deteriorated, he was taken to West Suffolk Hospital and then on to Ipswich Hospital. He was placed in a seclusion room under constant observation. The next day, January 12, he was found unresponsive after suffering a cardiac arrest. He never regained consciousness.

At the time then-director of quality and nursing Jane Sayer said: “At NSFT we have already reviewed our rapid tranquilisation policy and improved training for our staff.”